Faysal Ghazzay Ahmed Case Presentation He is 49 years old male living in Al-Qaem Town (Al-Anbar Gov.), Muslim, and was previously serving in the army, but now he is idle. He was admitted to Al-Jumhoory H. on 12 th of September 2011 complaining from Hoarseness of voice and progressive difficulty of swallowing for 6 months. Examined on 13 th of October 2011.
The patient is heavy smoker, smokes 3 Packs/day since 1981. His condition started 6 months ago, as lump in the middle of the neck after tooth extraction. This lump gradually increased in size, associated with throat discomfort & burning sensation followed by gradual change in voice. Within the following 4 months the voice progressively became hoarsy associated with difficulty of swallowing of both solids and liquids. The patient also reported pain of the left ear, the patient denies having stridor, anorexia or fever.
He sought medical help at Al-Ramadi H. and had A CT Scan of the neck which necessitated the advice of an ENT specialist. Then he consulted ENT department at Al-Jumhoori Teaching Hospital were an operation was arranged for him. Five days after admission he developed breathing difficulty which necessitated tracheostomy operation. Meanwhile direct laryngoscopy was done and biopsy was taken for histopathological examination. Although he denies to have previous medical illness, after admission he had high blood sugar that required insulin therapy.
Respiratory System: He has productive cough with yellowish to green sputum, sporadically at day or night time, with bad breath odor, difficulty in breathing with no cyanosis. Gastro intestinal System: He had weight loss of nearly 20-25 kg since the illness started, good appetite despite difficulty of swallowing, constipation, and abdominal discomfort. Cardiovascular System: No history of note. Musculoskeletal: No history of note. Central Nervous System: No history of note.
Past Medical History: No History of chronic disease of note nor any same illness before. Drug History : Not on chronic drug use, no known drug allergy. Past Surgical History: No previous history of operation. Personal Habits: Heavy smoker 3 packs / Day for 30 years, not alcoholic, no recreational drug abuse Social & Family History : Fair socio-economic status, with no similar condition in a family member
Middle aged tracheostomized male patient sitting on bed looking tired, conscious, alert, pale but not dyspneic & not cyanosed, no back or leg edema. He is afebrile, with Pulse rate of 80 PpM, Respiratory Rate of 30 BpM, BP was 130 / 90 mmhg.
Examination of the neck Left anterior triangle neck lump, level 2, 4-5 cm in diameter. The lump was firm, nearly pear shaped, with irregular surface and poorly defined edges. It was not tender, not hot,not compressible or reducible, fluctuation and trans illumination negative The overlying skin was not tethered, of normal color and texture. Other regional lymph nodes were not palpable Oral Cavity Bad oral hygiene with missing teeth. The others stained with brownish color Fiber optic laryngoscopy : Showed left glottic, supra and sub glottic mass, 2-3cm in diameter, reddish in color. The left vocal cord was immobile.
CT Scan of the neck : To assess the nature and extent of the mass, and the surrounding soft tissue and lymph nodes involvement.
Revealed moderately differentiated squamous cell carcinoma
Treatment Gluck-Sorenson's incision made
Apron Flap elevated
Total Laryngectomy with Left hemi thyroidectomy and left radical neck dissection. Left Hemi-thyroid Larynx
Followed by reconstruction of the pharynx by 3 layers suturing
Lymph nodes of the neck is a barrier that prevent further spread of the disease. What are the levels of neck lymph nodes??
These can be radical or selective. Involves removal of all five levels of lymph nodes together with the accessory nerve, internal jugular vein, sternomastoid muscle. 1. Type 1 : (modified radical neck dissection) preserves the accessory nerve. 2. Type 2 : preserves the accessory nerve and internal jugular vein. 3. Type 3 : preserves the accessory nerve, internal jugular vein, and sternomastoid muscle.
Hayes Martin strongly urged that a lymph node biopsy should be the last investigation to be done and that a search for the primary tumor must be made, if as a last resort, the operation must be performed by a surgeon who is able and willing to treat the primary cancer if it is later found. 1. Local and possibly general spread of the disease. 2. Compromise of subsequent neck dissection and irradiation. 3. Additional scar tissue causing difficulty in accurate palpation. 4. A false sense of security for the patient.
History. Thorough general and ENT examination. FNAC. Imaging: CT, MRI, Barium swallow. Hematological investigations. Panendoscopy UGA: If no primary site is identified, blind biopsies from nasopharynx, tongue base, pyriform and unilateral tonsillectomy. Lymph node biopsy with RND